René Botha outlines the most important things you need to know about your oncology benefit.
From the moment a patient receives a cancer diagnosis, there are multiple appointments lined up with different specialists, tests are booked and treatment plans are presented with costs that can seem overwhelming. This is the point at which patients rely on their medical aids or medical insurers to pay for whatever is needed. However, not many patients fully understand the ins and outs of what their oncology benefits may pay.
There are two types of medical cover in South Africa, medical insurance and medical aid. It’s important to understand the difference between these two to understand the oncology cover.
Medical insurance vs. medical aid
Although medical insurances and medical aids both provide medical cover, the methods in which this cover is provided are not the same. Primarily, the laws and regulations that apply to medical insurances are not the same as those that apply to medical aids. Therefore, there are substantial differences in the cover provided.
Some medical insurances don’t provide any oncology cover at all while others provide set amounts based on the policy selected and the stage of the disease. Certain insurers allow patients or service providers to submit claims directly to them, subject to the insured limit, and others pay a lump sum to the patient and the treatment must then be funded by the patient. This amount is not dependent on the treatment planned and may not always be sufficient to cover all treatments. Patients who have elected medical insurance instead of medical aid should check their benefits with their insurer to know what may and may not be covered.
All medical aids, including hospital plans, have a legal obligation to provide a certain amount of oncology cover, and such have a specifically dedicated benefit, called the oncology benefit, to fund the costs related to cancer treatment. This benefit only becomes available once the patient’s diagnosis has been registered with the medical aid. This is done by sending proof of the malignancy, such as a biopsy report, to the medical aid’s oncology department. This may be done by the patient or the treating doctor and takes 24-48 hours to take effect. Oncology benefits renew annually, with some of the benefits running for a calendar year and others renewing on the date of the initial diagnosis.
Understanding your oncology benefit
The oncology benefit is designed to cover the costs related to cancer. This includes the staging investigations, such as radiological investigations and blood tests, and the actual cancer treatment, including systemic therapy and radiation therapy. Surgery is usually funded from the risk benefit, not the oncology benefit. The oncology benefit also covers investigations related to the cancer treatment, e.g. blood tests to monitor blood counts while on treatment, or supportive medications, like the medications used to treat cancer related pain and the side effects of the treatment.
The value of the oncology benefit is dependent on the medical scheme and the plan the patient is on and may vary significantly between plans. It’s essential for patients to understand the limits of their scheme and their plan. Even though a monetary value may be allocated to the oncology benefit, this doesn’t mean that a patient or treating oncologist may use this amount completely at their discretion.
Most investigations and treatments require pre-authorisation from the medical aid to be paid from the oncology benefit. A treatment plan needs to be submitted to the medical aid, which will be reviewed by a case manager, and only if it meets the treatment guidelines of the scheme will it be approved.
If the scheme feels that the proposed treatment plan doesn’t meet the funding criteria, it may be declined. The oncologist may motivate for the proposed treatment but this doesn’t guarantee approval for funding from the scheme. Each scheme has different rules and different exclusions and may reject treatments based on these rules.
Learning the lingo
Once a patient is registered on the oncology benefit of their medical aid scheme, there are many new terms that will be used in the application and approval of treatment plans. Understanding these will help patients maximise their benefits as well as manage expectations of what schemes may and may not pay for.
Medical aids rely on professional bodies for recommendations on how to fund cancer treatment.
These bodies include the South African Oncology Consortium (SAOC) and Independent Clinical Oncology Network (ICON) as well as the Council for Medical Schemes (CMS).
To regulate the medical schemes industry in South Africa, parliament has appointed an autonomous statutory body, CMS. As part of their mandate, CMS has defined prescribed minimum benefits (PMB), which are a set of defined benefits to ensure that all members of medical schemes, regardless of the plan they have selected, have access to certain minimum health services.
The costs of the diagnosis, treatment and care of PMB must be covered by the medical schemes as directed by the Medical Schemes Act. While cancer forms a part of the PMB list, not all treatments are included on the PMB list. The PMB list is reviewed regularly by specialists in each field and updated as needed to incorporate the basic standard of care.
Tiers or levels
SAOC and ICON categorise cancer treatments into tiers or levels to give funding recommendations. The considerations for the treatment tiers or levels are based on the current national standard of care, including treatments that are available in state facilities in South Africa, as well as the treatments that fall into the category of PMB, international recommendations which may include newer drugs or more advanced techniques, and ‘novel’ treatments that may be newly available and not yet included in the standard recommendations.
To manage costs and maintain the financial health of the schemes, certain medical aid plans may only allow funding for the lower tiers or levels and exclude the higher tiers of treatment. PMB treatments may never be excluded on any option.
Designated service providers
Another way in which schemes attempt to manage the cost of treatment is by appointing designated service providers (DSP) who have contracted to specific rates. These schemes encourage patients to make use of these service providers to lower the costs of treatment.
While the appointment of DSP is used to manage medical costs, it’s important for patients to know that this doesn’t mean they may not use a provider outside of the DSP network. However, this may incur costs in the form of non-DSP co-payments. Patients electing to use the services of a healthcare professional outside of the DSP network should enquire with the provider if there will be any co-payments for these services.
Additional insurance cover
Cancer treatments may stretch over many months, sometimes even years. During these months there may be times that symptoms of the cancer or the side effects of treatment may prevent patients from working to their full capacity. Along with the expenses that may not be covered in full by the medical aid, patients may also struggle with loss of income due to this. There are additional insurance policies that may assist patients undergoing cancer treatment.
Gap cover insurance may assist patients to cover some of the costs that may not be covered in full by the medical aid. Patients may also have dread disease insurance which can assist in covering expenses when patients are not able to work at full capacity and income is reduced.
When evaluating medical cover, it’s best to speak to an experienced broker who knows the different products well and will be able to give honest and accurate advice.
MEET THE EXPERT – René Botha
René Botha is a radiotherapist with a special interest in treatment planning. She works in private practice and is based at the Wits University Donald Gordon Medical Centre.
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